The document provides 12 triage scenarios with patient details and suggested triage scores. For each scenario, the triage score and brief rationale is given, focusing on airway, breathing, circulation, risk of deterioration, and urgency of treatment. Triage scores range from 1 to 5, with 1 indicating treatment is needed immediately and 5 being non-urgent. The scenarios cover a range of medical conditions and injuries seen in emergency departments.

1. TRIAGE SCENARIOS
• Justifying and Assigning Triage Scores

2. Scenario 1
• Violet is a 91 year old female of non-English speaking
background. She is brought to the hospital in her son’s car
after seeing the local doctor in the next town. You are called
to assist her to get out of the car. Her son tells you she is “very
sick”. You note that she is able to transfer to a wheelchair with
minimal assistance. According to her son, Violet fell three days
earlier and has bruised her right hip. She is able to walk,
though her hip is very painful. She is not distressed when
seated. Her blood pressure is 150/90, heart rate 88 and
respiratory rate 20. You are unable to ascertain her exact level
of pain, though she tells you she is alright.
• Triage score?
• Reasons?

3. Scenario 1
• Violet
• Triage Score 4
• Airway, breathing and circulation intact.
• Hip causing pain on movement but able to
weight-bear.
• Should wait no longer than 60 minutes

4. Scenario 2
• A father presents to the hospital at 2000hrs with his three and
a half year old daughter, Savannah, stating that she has had a
sore throat for “a day or two”. It started with a runny nose and
a fever, then yesterday she began complaining of a sore
throat. She has no cough or stridor, she demonstrates no
shortness of breath and her skin is pink and warm.
• Triage score?
• Reason?

5. Scenario 2
• Savannah
• Triage Score 4
• Airway, breathing and circulation are intact
• She is experiencing some discomfort from
her condition and should commence
treatment within 60 minutes.

6. Scenario 3
• Nic, a 38 year old arborist, has cut his left arm with a chain
saw. He was brought into the hospital by a workmate. He has
a deep laceration of about 10cm to the inner aspect of his
arm. The wound was bleeding “quite a bit” but the blood loss
has been controlled with firm bandaging. He tells you that the
wound is “not that painful” but he looks pale and is sweating.
His heart rate is 84 and his respiratory rate 20. His workmate
reports that the dressing was changed once, half an hour ago
because it was soaked with blood.
• Triage score?
• Reasons?

7. Scenario 3
• Nic
• Triage Score 3
• Airway and breathing are intact, no
haemodynamic compromise despite moderate
blood loss
• This patient should wait no longer than 30 minutes
before treatment is commenced
• A clean dressing and firm bandage should be
applied to the wound. A sling should be applied
and elevation of the arm should occur
• Retriaging will be required if haemodynamic
compromise or increased blood loss occur

8. Scenario 4
• Heidi, a 17 year old female, presents to the hospital
complaining if a sore throat. She has a hoarse voice and her
friend states that she has had muscular pain to her neck,
shoulders and back. She has been unwell for a few days, but
has come to the hospital today because she is having trouble
swallowing. You ask her to open her mouth and note that her
breath is foul-smelling. Her tonsils appear to be covered in
pus. Her temperature is 39.4 C.
• Triage score?
• Reason?

9. Scenario 4
• Heidi
• Triage Score 3
• Airway, breathing and circulation intact.
• Patient is septic and treatment should
commence within 30 minutes

10. Scenario 5
• Liam is a 23 year old male who presents to the hospital after
seeing a locum doctor. He is backpacking around Australia and
has been stating in a boarding house near the hospital. His
partner has brought him to the emergency department. He
has a 6 hour history of fever and lethargy. He has been
vomiting, and complains of a headache. The doctor gave him
IM Maxalon, it has had some effect. His temperature is 38.4°C,
and his partner points out a fine petechial looking rash n his
torso. He is drowsy but orientated to time, place and person.
• Triage score?
• Reason?

11. Scenario 5
• Liam
• Triage Score 2
• Airway, breathing and circulation are intact
• The patient has signs of
meningococcaemia and needs to
commence treatment within 10 minutes

12. Scenario 6
• Baz, 34 years old, was installing a ceiling fan with the
assistance of a friend in his own home. He received a 240 volt
charge to his right hand, and was thrown back against the
roof. His friend immediately switched off the power and called
an ambulance. Baz had a brief period of loss of consciousness,
but was alert when the ambulance crew arrived. His heart rate
is 80 and irregular and his respirations 20. He has a 5 cm
blackened area to his right hand. No exit wound is seen.
• Triage score?
• Reasons?

13. Scenario 6
• Baz
• Triage Score 2
• Airway, breathing and circulation are intact
• Likely full thickness burn from
electrocution indicates severe local trauma
with possible systemic involvement
• Should wait no longer than 10 minutes for
treatment

14. Scenario 7
• Hannah is a 41 year old woman who presents via ambulance
with n altered conscious state following collapse. She is 30
weeks pregnant (G3 P1) and is normally well. She was out
shopping with a friend when she suddenly collapsed.
Ambulance officers report a fluctuating conscious state. At the
scene she tolerated an oropharyngeal airway but spat it out
on route. She is in a lateral position on the ambulance trolley
with supplemental oxygen via mask. Her respiratory rate is 10;
her SaO2 is 93% and heart rate 130. her BP is 190/110 her
Glasgow Coma score is 10 out of 15. her temperature 36.3°C.
• Triage score?
• Reason?

15. Scenario 7
• Hannah
• Triage Score 1
• Airway may be compromised due to fluctuating
level of consciousness. There is additional risk to
her airway and breathing due to pregnancy. There
is hypoventilation and severe hypertension. There
is imminent risk of deterioration.
• Simultaneous assessment and treatment must
commence immediately

16. Scenario 8
• Hugh is a 54 year old male who was seen in the emergency
department with a fractured right radius and ulna 4 days ago.
He presents again because he says his cast is too loose and
needs to be replaced. He has no pain.
• Triage score?
• Reasons?

17. Scenario 8
• Hugh
• Triage Score 5
• This is a non urgent problem. However the
plaster needs to be assessed as it was
applied in the emergency department and
if it is loose will not effectively immobilize
the fracture

18. Scenario 9
• A mother presents with her six month old baby Rebecca, who
she says will not wake up. The child is breathing, but is floppy,
cannot be roused and has pinpoint pupils.
• Triage score?
• Reasons?

19. Scenario 9
• Rebecca
• Triage Score 1
• Airway is unstable and cardiac arrest is
imminent.
• The child requires simultaneous
assessment and treatment

20. Scenario 10
• Antony, 56 years, was opening a tin of paint stripper with a
knife and some of the chemical splashed up into his right eye.
He ran water from the tap over his eye for fifteen minutes,
before his partner drove him to hospital. At triage he appears
very uncomfortable; the eye is closed and there is blistering to
the skin surrounding the right orbit.
• Triage score?
• Reasons?

21. Scenario 10
• Antony
• Triage Score 2
• Airway, breathing and circulation are clear.
• There is chemical burn to the eye with
changed visual acuity
• This patient should receive treatment
within 10 minutes

22. Scenario 11
• Bluey, a solidly built male about 40 years of age and smelling
strongly of alcohol starts shouting at another patient whilst
sitting in the waiting room. He says he wants to see a doctor,
but before you can establish what is wrong, he stands up and
begins to threaten with a knife the other patients who are
waiting.
• Triage score?
• Reason?

23. Scenario 11
• Bluey
• Triage Score 1
• Immediate threat of physical violence
using a weapon
• Simultaneous security and clinical
response to aggression is required
immediately

24. Scenario 12
• Justin is a 22 year old male who comes to the hospital
concerned about a mole on his back. He says that his girlfriend
advised him to see a doctor and he is worried that “it might be
a melanoma”. The mole is large and irregular in shape; he says
it is itchy.
• Triage score?
• Reasons?

25. Scenario 12
• Justin
• Triage Score 5
• Airway, breathing and circulation are intact
• This is not an urgent problem, however
the lesion needs to be checked for
melanoma and this should occur within
two hours